Provider Demographics
NPI:1326524471
Name:MIESSAU, MCKENZIE SARA (ATC)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:SARA
Last Name:MIESSAU
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512
Mailing Address - Country:US
Mailing Address - Phone:203-824-9044
Mailing Address - Fax:
Practice Address - Street 1:181 WHITE ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6826
Practice Address - Country:US
Practice Address - Phone:203-824-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer